1. health and fitness
2. disease
3. aids and hiv

UNAIDS World AIDS Day Report | 2011
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How to get to zero:
Faster.
Smarter.
Better.
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The UNAIDS vision
0
ZERO NEW HIV INFECTIONS.
ZERO DISCRIMINATION.
ZERO AIDS-RELATED DEATHS.
Copyright © 2011
Joint United Nations Programme on HIV/AIDS (UNAIDS)
All rights reserved
ISBN: 978-92-9173-904-2 | UNAIDS / JC2216E
The designations employed and the presentation of the material in this publication do not imply the expression of any
opinion whatsoever on the part of UNAIDS concerning the legal status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries. UNAIDS does not warrant that the information
published in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.
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UNAIDS World AIDS Day Report | 2011
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UNAIDS has mapped a new framework
for AIDS investments, focused on
high-impact, high-value strategies.
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Foreword
We are here.
05
06
How to get to zero:
Faster.
Smarter.
Better.
12
24
36
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TRANSFORMING THE RESPONSE
We are on the verge of a significant breakthrough in the AIDS response. The
vision of a world with zero new HIV infections, zero discrimination, and
zero AIDS-related deaths has captured the imagination of diverse partners,
stakeholders and people living with and affected by HIV. New HIV infections
continue to fall and more people than ever are starting treatment. With research
giving us solid evidence that antiretroviral therapy can prevent new HIV
infections, it is encouraging that 6.6 million people are now receiving treatment in
low- and middle-income countries: nearly half those eligible.
Just a few years ago, talking about ending the AIDS epidemic in the near term
seemed impossible, but science, political support and community responses are
starting to deliver clear and tangible results.
Yet, to be effective, the AIDS response must be transformed. We need to move
from a short-term, piecemeal approach to a long-term strategic response with
matching investment. The road map for this vision is clear. The United Nations
General Assembly set bold new targets in its historic 2011 Political Declaration
on HIV/AIDS: Intensifying Our Efforts to Eliminate HIV/AIDS, with a focus on
clear, time-bound goals designed to bring about the end of HIV and also improve
human health across diverse communities.
To reach these targets and bring the end of AIDS in sight we must step on the
accelerator. Joining with partners, UNAIDS has mapped a new framework for
AIDS investments, focused on high-impact, high-value strategies.
The world cannot live up to the targets and spirit of the Political Declaration
unless countries and donors commit to using the tools available, focusing them
on the most effective programmes and investing accordingly.
Michel Sidibé
UNAIDS Executive Director
Under Secretary-General of the United Nations
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> We are here.
The state of the AIDS epidemic
21
%
More people than ever are living with HIV, largely due to greater access to
treatment.
At the end of 2010, an estimated 34 million people [31.6 million–35.2
million] were living with HIV worldwide, up 17% from 2001. This reflects the
continued large number of new HIV infections and a significant expansion
of access to antiretroviral therapy, which has helped reduce AIDS-related
deaths, especially in more recent years.
Annual new HIV infections
fell 21% between
1997 and 2010.
People Living with HIV
40 000 000
35 000 000
People
30 000 000
25 000 000
20 000 000
15 000 000
10 000 000
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
0
1990
5 000 000
People living with HIV
The number of people dying of AIDS-related causes fell to 1.8 million
[1.6 million–1.9 million] in 2010, down from a peak of 2.2 million [2.1
million–2.5 million] in the mid-2000s. A total of 2.5 million deaths have
been averted in low- and middle-income countries since 1995 due to
antiretroviral therapy being introduced, according to new calculations by
UNAIDS. Much of that success has come in the past two years when rapid
scale-up of access to treatment occurred; in 2010 alone, 700 000 AIDSrelated deaths were averted.
The proportion of women living with HIV has remained stable at 50%
globally, although women are more affected in sub-Saharan Africa (59% of
all people living with HIV) and the Caribbean (53%).
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There were 2.7 million [2.4 million–2.9 million] new HIV infections in 2010,
including an estimated 390 000 [340 000–450 000] among children. This
was 15% less than in 2001, and 21% below the number of new infections at
the peak of the epidemic in 1997.
The number of people becoming infected with HIV is continuing to fall,
in some countries more rapidly than others. HIV incidence has fallen in 33
countries, 22 of them in sub-Saharan Africa, the region most affected by the
AIDS epidemic.
New HIV Infections and AIDS-related deaths
4 000 000
3 500 000
2 500 000
2 000 000
1 500 000
1 000 000
New HIV infections
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
0
1991
500 000
1990
People
3 000 000
Globally new HIV infections peaked in 1997.
AIDS-related deaths
Sub-Saharan Africa
Sub-Saharan Africa remains the region most heavily affected by HIV. In
2010, about 68% of all people living with HIV resided in sub-Saharan
Africa, a region with only 12% of the global population. Sub-Saharan Africa
also accounted for 70% of new HIV infections in 2010, although there was
a notable decline in the regional rate of new infections. The epidemic
continues to be most severe in southern Africa, with South Africa having
more people living with HIV (an estimated 5.6 million) than any other
country in the world.
Almost half of the deaths from AIDS-related illnesses in 2010 occurred in
southern Africa. AIDS has claimed at least one million lives annually in subSaharan Africa since 1998. Since then, however, AIDS-related deaths have
steadily decreased, as free antiretroviral therapy has become more widely
available in the region.
The total number of new HIV infections in sub-Saharan Africa has dropped
by more than 26%, down to 1.9 million [1.7 million–2.1 million] from the
estimated 2.6 million [2.4 million–2.8 million] at the height of the epidemic
in 1997. In 22 sub-Saharan countries, research shows HIV incidence
declined by more than 25% between 2001 and 2009. This includes some
of the world’s largest epidemics in Ethiopia, Nigeria, South Africa, Zambia
and Zimbabwe. The annual HIV incidence in South Africa, though still
high, dropped by a third between 2001 and 2009 from 2.4% [2.1%–2.6%]
to 1.5% [1.3%–1.8%]. Similarly, the epidemics in Botswana, Namibia and
Zambia appear to be declining. The epidemics in Lesotho, Mozambique
and Swaziland seem to be levelling off, albeit at unacceptably high levels.
UNAIDS WORLD AIDS DAY REPORT | 7
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Caribbean
The Caribbean has the second highest regional HIV prevalence after subSaharan Africa, although the epidemic has slowed considerably since the
mid-1990s.
In the Caribbean region, new HIV infections were reduced by a third
from 2001 levels. HIV incidence has decreased by an estimated 25% in
the Dominican Republic and Jamaica since 2001, while in Haiti it has
declined by about 12%. Slowing HIV incidence and increasing access to
HIV prevention services for pregnant women have led to a steep decline in
the number of children newly infected with HIV and in AIDS-related deaths
among children.
250
%
In Eastern Europe and
Central Asia, the number of
people living with HIV
rose 250% from 2001 to 2010.
Unprotected sex is the primary mode of transmission in the Caribbean.
The number of people living with HIV has also declined slightly since
the early 2000s. Increased access to antiretroviral therapy has led to a
considerable drop in mortality associated with AIDS.
Asia
Although the rate of HIV prevalence is substantially lower in Asia than in
some other regions, the absolute size of the Asian population means it is
the second largest grouping of people living with HIV.
In South and South-East Asia, the estimated 270 000 [230 000–340 000]
new HIV infections in 2010 was 40% less than at the epidemic’s peak in
1996. In India, the country with the largest number of people living with
HIV in the region, new HIV infections fell by 56%.
The prevalence of HIV among key populations at higher risk of infection
– notably sex workers, people who inject drugs and men who have sex
with men – is high in several Asian countries although over time, the virus
is spreading to other populations. The overall trends in this region hide
important variations in the epidemics, both between and within countries.
In many Asian countries, national epidemics are concentrated in relatively
few provinces. In China, for example, five provinces account for 53% of the
people living with HIV1, while a disproportionately large share of Indonesia’s
burden is found in its Papua and West Papua provinces.2
Eastern Europe and Central Asia
In Eastern Europe and Central Asia, there was a 250% increase in the
number of people living with HIV from 2001 to 2010. The Russian
Federation and Ukraine account for almost 90% of the Eastern Europe and
Central Asia region’s epidemic. Injecting drug use remains the leading
cause of HIV infection in this region, although considerable transmission
also occurs to the sexual partners of people who inject drugs.
There is little indication that the epidemic has stabilized in the region, with
new HIV infections and AIDS-related deaths continuing to increase. After
slowing in the early 2000s, HIV incidence in Eastern Europe and Central
Asia has been accelerating again since 2008.
Unlike most other regions, AIDS-related deaths continue to rise in Eastern
Europe and Central Asia.
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Middle-East and North Africa
HIV-related trends in the Middle East and North Africa vary, as incidence,
prevalence, and AIDS-related deaths are on the rise in some countries,
while in others the epidemic is stable. Generally, HIV prevalence in the
region is low, except in Djibouti and Southern Sudan, where the epidemic
is becoming generalized.
Latin America
The HIV epidemics in Latin America are generally stable. A steady decrease
in new annual HIV infections since 1996 levelled off in the early 2000s and
has remained steady since then at 100 000 [73 000–135 000] each year.
The total number of people living with HIV in this region continues to grow.
That increase is partly attributable to the increase in people living with HIV
who receive antiretroviral therapy, which has helped reduce the number of
annual AIDS-related deaths. More than one third (36%) of adults living with
HIV in this region in 2010 were women.
The number of children younger than 15 living with HIV in this region has
declined. There was a considerable decrease in new HIV infections and
AIDS-related deaths among children between 2001 and 2010.
Oceania
The number of annual new HIV infections in Oceania increased slowly until
the early 2000s, and then declined. The number of people living with HIV
in this region reached an estimated 54 000 [48 000–62 000] at the end of
2010, about 34% more than the estimate for 2001. AIDS-related mortality
has decreased considerably.
North America, and Western and Central Europe
The HIV epidemic in North America and Western and Central Europe
remains stubbornly steady, despite universal access to treatment, care and
support and widespread awareness of the epidemic and the causes of HIV
infection. HIV incidence has changed little since 2004.
The total number of people living with HIV in North America and Western
and Central Europe reached an estimated 2.2 million [1.9 million–2.7
million] in 2010, about one third (34%) more than in 2001. More than half
(about 1.2 million) of the people with HIV in this region live in the United
States of America.
The rising number of people living with HIV reflects the wide-scale
availability of antiretroviral therapy, especially in the countries with the
largest epidemics, which has significantly reduced AIDS-related mortality.
The number of AIDS-related deaths has varied little since 2000, despite the
34% increase in the number of people living with HIV.
Recent trends vary across the region. Rates of diagnosed HIV cases
doubled between 2000 and 2009 in Bulgaria, Czech Republic, Hungary,
Lithuania, Slovakia and Slovenia and increased by more than 50% in the
United Kingdom. On the other hand, new HIV diagnoses decreased by
more than 20% in Latvia, Portugal and Romania.3
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Regional HIV and AIDS statistics, 2010 and 2001
Regional estimates of adults and children newly
infected with HIV, people living with HIV,
and AIDS-related deaths
Adults and children
living with HIV
Sub-Saharan
Africa
Middle East and
North Africa
South and
SOUTH-EAST ASIA
EAST ASIA
OCEANIA
Latin AMERICA
Adults and children
newly infected
with HIV
Adult prevalence
(%)
Adult and child
deaths due to AIDS
Young people (15–
24) prevalence (%)
MaleFemale
2010
22.9 million
[21.6–24.1 million]
1.9 million
[1.7–2.1 million]
5.0
[4.7–5.2]
1.2 million
[1.1–1.4 million]
1.43.3
[1.1–1.8][2.7– 4.2]
2001
20.5 million
[19.1–22.2 million]
2.2 million
[2.1–2.4 million]
5.9
[5.6– 6.4]
1.4 million
[1.3–1.6 million]
2.05.2
[1.6–2.7][4.3–6.8]
2010
470 000
[350 000–570 000]
59 000
[40 000–73 000]
0.2
[0.2–0.3]
35 000
[25 000 –42 000]
0.10.2
[0.1–0.2][0.1–0.2]
2001
320 000
[190 000–450 000]
43 000
[31 000– 57 000]
0.2
[0.1–0.3]
22 000
[9700 –38 000]
0.10.1
[0.1–0.2][0.1–0.2]
2010
4.0 million
[3.6– 4.5 million]
270 000
[230 000 –340 000]
0.3
[0.3–0.3]
250 000
[210 000 –280 000]
0.10.1
[0.1–0.2][0.1–0.1]
2001
3.8 million
[3.4–4.2 million]
380 000
[340 000– 420 000]
0.3
[0.3–0.4]
230 000
[200 000–280 000]
0.20.2
[0.2–0.2][0.2–0.2]
2010
790 000
[580 000–1.1 million]
88 000
[48 000 –160 000]
0.1
[0.1– 0.1]
56 000
[40 000–76 000]
<0.1<0.1
[<0.1–<0.1][<0.1–<0.1]
2001
380 000
[280 000– 530 000]
74 000
[54 000 – 100 000]
<0.1
[<0.1– 0.1]
24 000
[16 000 –45 000]
<0.1<0.1
[<0.1–<0.1][<0.1–<0.1]
2010
54 000
[48 000–62 000]
3300
[2400–4200]
0.3
[0.2 – 0.3]
1600
[1200–2000]
0.10.2
[0.1–0.1][0.1–0.2]
2001
41 000
[34 000–50 000]
4000
[3300–4600]
0.2
[0.2– 0.3]
1800
[1300 –2900]
0.10.2
[0.1–0.2][0.2–0.3]
2010
1.5 million
[1.2–1.7 million]
100 000
[73 000–140 000]
0.4
[0.3– 0.5]
67 000
[45 000–92 000]
0.20.2
[0.1–0.4][0.1–0.2]
2001
1.3 million
[1.0 –1.7 million]
99 000
[75 000–130 000]
0.4
[0.3– 0.5]
83 000
[50 000–130 000]
0.20.1
[0.1–0.6][0.1–0.2]
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Adults and children
living with HIV
CARIBBEAN
Adults and children
newly infected
with HIV
Adult prevalence
(%)
Adult and child
deaths due to AIDS
Young people (15–
24) prevalence (%)
MaleFemale
2010
200 000
[170 000–220 000]
12 000
[9400–17 000]
0.9
[0.8–1.0]
9000
[6900–12 000]
0.20.5
[0.2–0.5][0.3–0.7]
2001
210 000
[170 000–240 000]
19 000
[16 000–22 000]
1.0
[0.9–1.2]
18 000
[14 000–22 000]
0.4
0.8
[0.2–0.8][0.6–1.1]
EASTERN EUROPE
and
CENTRAL ASIA
2010
1.5 million
[1.3–1.7 million]
160 000
[110 000–200 000]
0.9
[0.8–1.1]
90 000
[74 000–110 000]
0.6
0.5
[0.5–0.8][0.4–0.7]
2001
410 000
[340 000–490 000]
210 000
[170 000–240 000]
0.3
[0.2–0.3]
7800
[6000–11 000]
0.30.2
[0.2–0.3][0.1–0.2]
WESTERN and
CENTRAL EUROPE
2010
840 000
[770 000–930 000]
30 000
[22 000 –39 000]
0.2
[0.2–0.2]
9900
[8900–11 000]
0.10.1
[0.1–0.1][<0.1–0.1]
2001
630 000
[580 000–690 000]
30 000
[26 000–34 000]
0.2
[0.2–0.2]
10 000
[9500–11 000]
0.1
0.1
[0.1–0.1][0.1–0.1]
2010
1.3 million
[1.0–1.9 million]
58 000
[24 000–130 000]
0.6
[0.5–0.9]
20 000
[16 000–27 000]
0.3
0.2
[0.2–0.6][0.1–0.4]
2001
980 000
[780 000–1.2 million]
49 000
[34 000–70 000]
0.5
[0.4–0.7]
19 000
[15 000–24 000]
0.3
0.2
[0.2–0.4][0.1–0.3]
2010
34.0 million
[31.6–35.2 million]
2.7 million
[2.4–2.9 million]
0.8
[0.8–0.8]
1.8 million
[1.6–1.9 million]
0.3
0.6
[0.3–0.3][0.5–0.6]
2001
28.6 million
[26.7–30.9 million]
3.1 million
[3.0–3.3 million]
0.8
[0.7–0.8]
1.9 million
[1.7–2.2 million]
0.40.8
[0.4–0.4][0.7–0.8]
NORTH AMERICA
TOTAL
Methodologies
In collaboration with country partners, UNAIDS used the Spectrum software package to develop the epidemiology
estimates for countries and regions cited in this report. Spectrum incorporates all pertinent, available data, including:
surveys of pregnant women attending antenatal clinics; population-based surveys (conducted at the household
level); sentinel surveillance among populations at higher risk of HIV infection; case reporting; demographic data;
and information on antiretroviral treatment programmes and programmes to prevent mother-to-child transmission.
Taking these diverse data sources into account, Spectrum generates estimates of new HIV infections, the number of
people living with HIV both for adults and children, the number of people eligible for antiretroviral therapy and for
services to prevent mother-to-child transmission, and the number of AIDS-related deaths.
These new HIV estimates (including the estimates for previous years) supersede those published previously and
should not be compared to earlier reports. Previously published UNAIDS estimates for Latin America did not include
Mexico, which is now included in this region.
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> Faster.
Smarter.
Better.
UNAIDS WORLD AIDS DAY REPORT | 13
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>Faster.
20
%
Antiretroviral coverage rose
20% in sub-Saharan Africa
between 2009
and 2010.
Accelerating the epidemic’s decline
The world faces a clear choice: maintain current efforts and make
incremental progress, or invest smartly and achieve rapid success in the
AIDS response.
The unparalleled global response of the past decade has already forced
the epidemic into decline. The rate of new HIV infections has fallen,
the number of AIDS-related deaths has decreased and unprecedented
funding has been mobilized for HIV programmes. Historic political
agreements had a demonstrable impact on the AIDS epidemic, including
the 2001 Declaration of Commitment on HIV/AIDS and the 2006 Political
Declaration on HIV/AIDS which endorsed the goal of universal access to
HIV prevention, treatment, care and support.
A decade ago, when world leaders convened in New York for the United
Nations General Assembly Special Session on AIDS – the first time they
did so for a health issue – only three countries, Senegal, Thailand and
Uganda, stood out as having successfully responded to HIV. Today almost
every country in sub-Saharan Africa, Asia and Latin America has a success
story to tell, a story of lives saved through stopping new HIV infections
and preventing AIDS-related deaths. In a decade, committed political
leadership, social change, innovation and rapid injection of new resources
have transformed the AIDS response into a vanguard of global health
success. The AIDS response has reinvigorated interest in global health and
now has a new face of hope, resilience, courage and responsibility.
Behaviour change is averting new HIV infections,
especially among young people
Declines in new HIV infections across the world have been spurred by
changes in behaviour among young people, sex workers and their clients,
people who inject drugs, men who have sex with men and transgender
people. Access to HIV prevention services has empowered individuals and
communities to act in earnest against the disease.
In countries with generalised epidemics, a combination of behaviour
changes, including reductions in numbers of sexual partners, increases in
condom use, and delayed age of first sex, have reduced new infections
(incidence) in several countries. HIV incidence in urban Zimbabwe fell from
an extremely high peak of almost 6% in 1991 to less than 1% in 2010.4
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The world faces a clear choice:
maintain current efforts and
make incremental progress, or invest
smartly and achieve rapid success
in the AIDS response.
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New HIV infection trends
The course of new HIV infections, compared to
estimates if key changes had not happened
CAMBODIA
NYANZA PROVINCE, KENYA
44 000
60 000
1990
1995
2000
2010
Adult new HIV infections
New HIV infections
Adult new HIV infections if condom
use by sex workers and clients had
remained at 1994 levels
New HIV infections in the absence of
voluntary medical male circumcision
GLOBAL NEW HIV INFECTIONS
AMONG CHILDREN
URBAN MALAWI
35 000
1995
2005
600 000
2000
2005
2000
2005
2010
Adult new HIV infections
New HIV infections among children
Adult new HIV infections in the
absence of behaviour change
New HIV infections among children
in the absence of treatment
Modelling suggests that without behaviour change, HIV incidence would
have remained twice as high as current levels, resulting in an additional
35 000 new infections annually. A similar story can be seen in urban areas
of Malawi, where in the absence of changes in sexual behaviour, the rate of
new HIV infections would have stabilised at about 4% annually but instead
dropped to less than 1% in 2010, avoiding about 15 000 new infections
annually.5
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A new generation of young people are taking charge of their destinies and
are protecting themselves against HIV. Encouraging trends are evident
among young people in several countries with large HIV burdens.
HIV prevalence declined among young people (aged 15–24 years) in at
least 21 of 24 countries with national HIV prevalence of 1% or higher. The
drop in HIV prevalence was statistically significant among pregnant women
attending antenatal clinics in 12 countries: Burkina Faso, Botswana, Congo,
Ethiopia, Ghana, Kenya, Malawi, Nigeria, Namibia, the United Republic of
Tanzania, Togo, and Zimbabwe. Four of those countries (Botswana, Malawi,
Tanzania and Zimbabwe) also had statistically significant declines in the
general population, according to results from population-based surveys
(among women in Botswana, Malawi and Zimbabwe, and among men in
Tanzania). Three other countries had statistically significant declines in the
general population, but showed no significant declines among antenatal
clinic attendees (among women in Zambia, and among men in Lesotho and
South Africa).
These declines have occurred amid signs of encouraging changes in sexual
behaviour among young people. The percentage of young men with
multiple partners in the past 12 months decreased significantly in 11 of the
19 countries with sufficient data, and among women it decreased in six
countries. The proportion of young people who said they used a condom
the last time they had high-risk sex increased significantly in seven (for men)
and five (for women) of the 17 countries with sufficient data. The percentage
of young men and women who have had sex before their 15th birthday
decreased significantly in eight of the 18 countries with sufficient data.
Important dimensions of social change have also reinforced measured
changes in behaviour and incidence. For example, community-based
participatory learning approaches can be effective in changing social
gender norms, including violence, when HIV and violence prevention
programming are paired with community mobilization and engaging
men to challenge harmful gender norms. A landmark study in South
Africa recently suggested that nearly one in seven cases of young women
acquiring HIV could have been prevented if the women had not been
subjected to intimate partner violence.6
Behavioural changes have been particularly notable in countries with
high HIV prevalence, although variations exist across these countries as
behavioural patterns continue to evolve, sometimes for the worse. For
example, in Rwanda and Zimbabwe, the proportion of young women with
multiple partners increased and a similar trend was observed among young
men in Guyana and Lesotho. Condom use by young men in Uganda and
Zimbabwe appears to have decreased and the proportion of young people
having sex before the age of 15 increased in Guyana, Lesotho and Haiti,
and among young men in Rwanda.
Additionally, in many countries with high HIV prevalence, young men are
beginning to get circumcised. Clinical trials in Kenya, South Africa and
Uganda indicate that voluntary medical male circumcision reduces the risk
of female-to-male sexual transmission by about 60%.7-9 Preliminary results
from cross-sectional surveys of the Orange Farm community in South
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Africa that is introducing voluntary medical male circumcision programmes
demonstrate the effectiveness of this approach.10 An estimated 2000
new HIV infections were averted through 2010 among men in Kenya’s
Nyanza province, after scale-up of voluntary medical male circumcision
programmes.
Voluntary medical male
circumcision in Kenya
Kenya could prevent 73 000 new HIV infections in 2011–2025 if 80%
of uncircumcised adult males were circumcised by 2015, and that
coverage level is maintained. Achieving this will require 860 000
circumcisions. By the end of 2010, 232 287 circumcisions had already
been performed, which was 27% of the national target, and Nyanza
Province achieved 62% of its 2015 target.11
Continued investments in behaviour change programmes have the
potential to further accelerate the drop in new HIV infections.
While young men have proved the
most ready to take up the option
of medical male circumcision, to
maximize its benefits older men
also need to be reached. To achieve
the population-wide prevention
benefit of voluntary medical male
circumcision in Eastern and Southern
Africa, 20 million more males need
to be circumcised. If this goal is
achieved, it will avert approximately
3.4 million new HIV infections by
2015.
Acceleration through a focus on people at higher risk
of HIV infection
A focus on people at higher risk of HIV infection in countries with
concentrated epidemics has borne fruit, although in many cases, these
gains are limited and much more can be done. In Cambodia consistent
condom use among sex workers and their clients increased from about
40% in 1997 to current levels of over 90% and new HIV infections have
dropped to fewer than 2000 per year. Had condom use rates remained at
1994 levels, before the increase in condom use, the annual number of new
HIV infections is likely to have been more than 50 000.12 Similar success has
been observed in Cotonou, Benin, where there is estimated to be 30004000 fewer new infections annually as a result of an intensive behaviour
change programme with sex workers.13
Invest in young leaders
With the aim of slowing the spread of HIV, the 2011 Political
Declaration calls on all countries to encourage and support the
active involvement of and leadership by young people in the global,
regional and national responses. Particular steps are needed to
ensure robust participation by young people in Country Coordinating
Mechanisms and national AIDS coordinating bodies. In addition, the
2011 Political Declaration pledges specific steps to engage young
people living with HIV, and to engage young people on HIV in
communities, families, schools, recreation centres and workplaces.
The HIV Young Leaders Fund is enabling new leadership among
young people most affected by HIV. The Fund has provided 23 grants
to community projects in 19 countries since 2010 and is encouraging
youth-led initiatives in advocacy, peer-based services and community
mobilization. Young people determine where grants go and also
provide technical support.
18 | UNAIDS WORLD AIDS DAY REPORT
In Dhaka, Bangladesh, harmreduction programmes have been
credited with slowing the spread of
HIV among people who inject drugs.
HIV prevalence in this population
rose from 1.4% in 2000 to 7%
in 2007, but thereafter dropped
to 5.3% in 2011, well below the
levels observed in areas without
prevention programmes. Where
countries ignore harm-reduction
programmes or do not take HIV
prevention programmes to scale,
the consequences have been
severe. In St Petersburg, Russia, HIV
prevalence has doubled in the past
five years, with estimates of almost
60% HIV prevalence among people
who inject drugs.14
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People who inject drugs also
Reducing harm in Iran
need equitable access to nondiscriminatory health and social
An estimated 15% (5%–25%) of people who inject drugs in Iran are
services. Studies in Eastern Europe
living with HIV.18 In response, the country has created a network of
and Central Asia show many people
more than 600 clinics that address drug injection, HIV and sexually
who inject drugs actively avoid
transmitted infections.19 About half of all people who inject drugs in
seeking health services due to the
Iran receive opioid substitution, while 40 clean syringes and needles
risk of ostracism or fears that their
are distributed each year per person who injects drugs.20 With this
health providers will report them to
national network in place, HIV prevalence has declined steadily since
law enforcement authorities.15 Such
peaking in 2005.21
obstacles limit individuals’ access
to basic health services, such as
counselling in sexual risk reduction
and treating sexually transmitted
infections, as well as antiretroviral therapy for people who are HIV-positive.
ANTIRETROVIRAL TREATMENT is key to faster progress
While declines in new infections resulting from changes in behaviours show
a clear return on the investments made in the HIV prevention response,
initial declines are often followed by a stabilisation of rates of new
infections. A pattern is emerging of initial peaks in new infections, followed
by a reduction in new infections as prevention efforts are taken to scale and
behaviours change, followed by a plateauing of rates of new infections,
often at relatively high levels. Recent evidence suggests this plateau effect
can be broken by the added prevention benefit of high levels of treatment
coverage.16
The most dramatic increases in antiretroviral therapy coverage have occurred
in sub-Saharan Africa, with a 20% increase between 2009 and 2010 alone.
It is estimated that at least 6.6 million people in low- and middle-income
countries are receiving HIV treatment. This is an increase of more than 1.35
million over the previous year. In low- and middle-income countries 47% of
the 14.2 million eligible people living with HIV were on antiretroviral therapy
at the end of 2010, compared to 39% at the end of 2009.
Universal access to treatment (defined as 80%, or greater coverage) has
been achieved in Botswana, Namibia and Rwanda, while Swaziland and
Zambia have achieved coverage levels between 70% and 80%. Across
cities and villages in sub-Saharan Africa, from Harare to Addis Ababa to
rural Malawi and South Africa’s Kwazulu Natal province, introducing HIV
treatment has dramatically reduced AIDS-related mortality.17 In low- and
middle-income countries globally, treatment has averted 2.5 million AIDS
deaths since 1995, the majority in the past few years.
Access to treatment boosts the success of combination
HIV prevention programmes
In addition to improving quality of life and reducing AIDS-related deaths,
antiretroviral treatment is now recognized as preventing HIV transmission
by reducing viral load and hence reducing the potential for transmission.
Coupling treatment access with combination prevention options is
pushing new HIV infections down to record levels. In countries with adult
HIV prevalence in excess of 10%, HIV treatment in combination with
UNAIDS WORLD AIDS DAY REPORT | 19
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Proportion of eligible population receiving antiretroviral therapy
in low- and middle-income countries at the end of 2010
Rapid increases in ART coverage are helping more countries achieve
universal access to treatment, care and support.
20%–39%
Algeria
Angola
Armenia
Azerbaijan
Bangladesh
Bhutan
Bolivia
Bulgaria
40%–59%
Burundi
Belarus
Cameroon
Belize
CAR
Benin
Chad
Burkina Faso
China
Cape Verde
Colombia
Congo
Côte d’Ivoire
El Salvador
Equatorial Guinea
Eritrea
Fiji
Gabon
Gambia
Guatemala
Ghana
Guinea
Hungary
Guinea-Bissau
India
Haiti
Indonesia
Honduras
Kazakhstan
Jamaica
Lebanon
Lao PDR
Liberia
Lesotho
Afghanistan
Lithuania
Malawi
DR Congo
Malaysia
Mali
Djibouti
Mauritania
Mozambique
Argentina
Egypt
Mongolia
Oman
Brazil
Iran
Morocco
Papua New Guinea
Costa Rica
Kyrgyzstan
Myanmar
Peru
Dominican Rep
Latvia
Niger
Philippines
Ecuador
Botswana
Madagascar
Nigeria
Senegal
Ethiopia
Cambodia
Maldives
Panama
South Africa
Georgia
Chile
Mauritius
Poland
Suriname
Kenya
Comoros
Nepal
Rep. of Moldova
Togo
Mexico
Croatia
Pakistan
Russian Fed
Turkey
Paraguay
Cuba
Somalia
Sao Tome and Principe
Uganda
Romania
Namibia
Sudan
Serbia
UR Tanzania
Swaziland
Nicaragua
Tajikistan
Sierra Leone
Venezuela
Thailand
Guyana
Tunisia
Sri Lanka
Viet Nam
Uruguay
Rwanda
Ukraine
Uzbekistan
Zimbabwe
Zambia
Slovakia
0%–19%
Source: UNAIDS and WHO, 2011.
20 | UNAIDS WORLD AIDS DAY REPORT
60%–79%
>80%
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behaviour-change programmes and medical male
circumcision programmes may be the key to achieving
rapid declines in new HIV infections.
The case for home HIV testing
The fact that fewer than half of those living with
HIV do not know it is a huge barrier to treatment
scale up and realizing the benefits of treatment
for prevention. The situation in some of the worst
affected areas is even more dire: a recent national
study in Kenya showed only 16% of HIV-infected
adults knew that they were infected.23
Namibia is in the forefront of reaping benefits of such
an approach. Over the last decade there has been a
concurrent scale-up of HIV prevention and treatment
programmes. Condom use has increased to nearly
75% among men; fewer than 11% of men and 2% of
women had multiple partners; and young people,
particularly boys, were starting to have sex at an older
age. Treatment access has reached an all-time high of
90%. The combined impact contributed to a 60% drop
in new HIV infections by 2010, from 22 000 in 1999.
A variety of tests, from finger pricks to mouth
swabs, can now produce results in 1–20 minutes.
The cost of these tests is now measured in cents.
Data from hyperendemic countries suggest that
behaviour change programmes are crucial to bring
down new HIV infections. However after initial dips,
the numbers of new HIV infections tend to stabilize,
sometimes at relatively high levels. The introduction of
new HIV prevention tools such as male circumcision and
HIV treatment can break this stalemate.
Despite the advances in technology, testing is
still approached with fear, accessing clinics is
inconvenient and the experience of HIV testing is
often stigmatizing.24 One model has estimated that
up to half of new HIV infections among children are
caused by stigma, because women refuse to take
tests or fail to collect their results.25
In countries that have achieved high levels of treatment
coverage, new infections may be declining even in the
absence of any significant changes in patterns of sexual
behaviour. In Zimbabwe, for example, a decline in new
HIV infections took place between 1995 and 2000.
This was followed by a period of relatively stable HIV
incidence of 1% – more than 50 000 new HIV infections
per year. However in recent years new HIV infections
have begun to decline, coinciding with scale-up of HIV
treatment and no significant national level changes
in sexual behaviour. Similarly, recent declines in new
HIV infections in Lesotho are particularly noteworthy
as they have occurred in conjunction with an increase
in risk-taking behaviour among some populations.
The drop in new HIV infections can, at least in part, be
attributed to the increased number of people accessing
treatment alongside the prevention effect of current
HIV prevention programmes.22
In countries where universal access to treatment has
been achieved, the results are more pronounced. In
Botswana, early declines in new HIV infections may
be explained by the natural course of the epidemic
together with a dramatic increase in condom use
between 1988 and 2000 (according to the 1988
Demographic and Health survey in Botswana only 10%
of adult women reported ever having used a condom).
Since 2000, patterns of sexual behaviour have remained
relatively stable leading to a slowing of the declines in
new HIV infections. However in this period, Botswana
One option to radically shift test access is selftesting at home. Information and support could be
provided remotely. Most importantly, those who
tested positive would need a clear access path to
health care, starting with a confirmatory test.
In September 2011, the United Kingdom’s House
of Lords select committee on AIDS recommended
repealing laws that prohibit home HIV testing.26 The
Terrence Higgins Trust has found “a clear bedrock
of support” for legalizing HIV home-testing kits,
particularly among gay men.27 iTeach, an outreach
programme at Edendale Hospital in KwaZulu-Natal
in South Africa, has been grappling with self-testing
models for one of the world’s hardest hit locations28
and they have pointed to the irony that test kits are
kept under lock and key because otherwise health
care workers would access them informally – an
issue examined by the World Health Organization
earlier this year.29
Edwin Cameron, Justice of the Constitutional Court
in South Africa, is an advocate for home testing
and has said that knowing your HIV status “simply
ought to be a part of life”. He has said that people
have a right to access accurate tests and use them
in the privacy of their own home; that it won’t
solve every problem of accessing treatment and
care or negotiating safe sex, but is “a simple and
affordable way to take the first step.”
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New infections, behaviour change and
treatment coverage in Botswana
Behaviour change
100%
Condom use at last sex (all respondents) (males, %)
Condom use at last sex (all respondents) (females, %)
Only 1 partner in last year (females, %)
Only 1 partner in last year (males, %)
50%
2005
2000
0%
New infections and
treatment coverage
35 000
100%
90%
30 000
80%
25 000
70%
60%
20 000
50%
15 000
40%
10 000
30%
20%
5 000
New infections
2010
2005
2000
1995
0
10%
0%
Treatment coverage (%)
Source: Botswana AIDS indicator surveys; UNAIDS; WHO.
has also rapidly increased provision of antiretroviral treatment. Botswana was
the first African country to implement a free national antiretroviral therapy
programme. Treatment for HIV is now available in 30 hospitals and 130
satellite clinics countrywide. Since 2009, Botswana has maintained more
than 90% of eligible people on treatment.30
There are early signs that this increase in access to treatment is contributing
to acceleration of the decline in new HIV infections. Data from modelling
suggests that the number of new HIV infections is 30% to 50% lower now
than it would have been in the absence of universal access to treatment for
eligible people living with HIV.
The full preventive effect of HIV treatment will be seen in the next 1–5
years, as increasing numbers of hyperendemic countries reach high levels
of coverage. The massive increases in the numbers of people receiving
treatment in South Africa between 2009 and 2010, for example, are likely
to be reflected in substantially fewer new infections in the near future.
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A major factor limiting the prevention dividend of HIV treatment, however,
is that more than 60% of people living with HIV are unaware of their HIV
status. This limits access to treatment and care services and hampers
prevention efforts. New approaches to HIV testing need to be explored to
increase knowledge of HIV status. While integrating HIV testing into routine
health services has helped to increase testing, it is insufficient. Introducing
community-based approaches to testing may help to increase accessibility
and uptake, and therefore, increase levels of knowledge of HIV status.
Accelerating the decline in tuberculosis deaths
Without treatment and prophylaxis, people living with HIV have a 20–30
times higher lifetime risk of developing active tuberculosis, compared with
people without HIV.31 In 2010, people living with HIV accounted for about
13% of all new tuberculosis cases worldwide, and about 360 000 people
died from HIV-related tuberculosis.32
The number of tuberculosis deaths
among people living with HIV
has been declining since 2004.
Close collaboration between HIV
and tuberculosis programmes can
accelerate this decline further to
meet the global goal of halving the
number of HIV-related tuberculosis
deaths by 2015.
South Africa boosts collaborative TB/HIV care
South Africa suffers the world’s greatest burden of HIV and
tuberculosis, yet it is making great strides to address both diseases.
About 210 000 people with tuberculosis were tested for HIV in 2010
and 60% were identified as HIV-positive. More than half were started
on antiretroviral therapy and three quarters received cotrimoxazole
preventive therapy. In the same year, almost 60% of the 3.9 million
people in HIV care were screened for tuberculosis, with 12%
given isoniazid preventive therapy. An HIV counselling and testing
campaign that included tuberculosis screening also resulted in
760 000 people with HIV being screened for tuberculosis, of which
120 000 were provided with isoniazid preventive therapy.34
Tuberculosis care, cure and
prevention should increase among
people living with HIV. Less than
a third of people living with HIV
sought care for tuberculosis at a
clinic in 2010. Halving HIV-related
tuberculosis deaths requires this rate to double, together with an increase
in tuberculosis cure rates from 70% to 85%, detection of at least 80% of
tuberculosis cases among people living with HIV, and isoniazid preventive
therapy reaching at least 30% of people living with HIV who do not have
active tuberculosis.
Regular screening and testing should be offered in countries with high
prevalence of HIV and tuberculosis, and more sensitive and specific
diagnostic tools and algorithms should be used. An inexpensive daily
dose of isoniazid significantly reduces the risk that latent tuberculosis will
progress to active disease.31 At least 30% of people living with HIV who do
not have active tuberculosis should receive isoniazid preventive therapy.
Antiretroviral therapy should be initiated in a timely manner, because
earlier treatment substantially reduces the odds of HIV-related tuberculosis
illness and death. Meeting the global goal on halving the number of HIVrelated tuberculosis deaths by 2015 will also require the goal of universal
access to HIV treatment to be met.33
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Faster.
> Smarter.
Better.
UNAIDS WORLD AIDS DAY REPORT | 25
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>Smarter.
Smart investments that drive increased
programme impact
The AIDS epidemic is not over yet, but the end may be in sight if countries
invest smartly. In the next five years, smart investments can propel the AIDS
response towards achieving the vision of zero new HIV infections, zero
discrimination and zero AIDS-related deaths. To ensure value for money,
lessons learned from the past three decades must be effectively applied.
Investing smartly, investing for results
The current economic crisis and dwindling international resources have
reduced the financial resources made available for the AIDS response. At the
end of 2010 about US$ 15 billion was available. International assistance has
declined from US$ 8.7 billion in 2009 to US$ 7.6 billion in 2010. The resilience
of the AIDS response has somewhat cushioned the adverse impact of this
reduction in resources, but the accumulated deficit in funding is one of the
factors that prevented the world from reaching all the goals set in 2001 for
2010. The future of AIDS resourcing depends on smart investing: spending
now to curtail the need to ‘spend more – forever’.
In June 2011, Member States agreed on a new set of global targets,
including making at least US$ 22–24 billion available for the global HIV
response annually by 2015. This level of resourcing is critical if the new
global goals are to be achieved. Even more critical is that these resources
are invested wisely in order to maximise return, to achieve value for money.
A new UNAIDS Investment Framework provides a roadmap for such an
approach, tying investments to concrete results.
The Investment Framework for the global HIV response starts with the
premise that, while there have been tremendous gains in the global
response to HIV, a systematic effort to match investment to needs has
so far been largely lacking. The resulting mismatch has stretched scarce
resources too thinly over too many objectives.
The framework represents a radical departure from current approaches,
and has four clear aims:
• Maximizing the benefits of the HIV response
• Using country-specific epidemiology to ensure rational resource
allocation
• Encouraging countries to implement the most effective programmes
based on local context
• Increasing efficiency in HIV prevention, treatment, care and support.
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The framework represents a radical
departure from current approaches,
and has four clear aims:
1.
Maximizing the benefits of the HIV
response
2.
Using country-specific epidemiology to
ensure rational resource allocation
3.
effective programmes based on
local context
4.
Increasing efficiency in HIV prevention,
treatment, care and support.
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Investment framework projections for new HIV infections
Optimized investment will lead to rapid declines in new HIV
infections in many countries.
viet nam
Cambodia
1990
2015
1990
russian federation
1990
nigeria
2015
1990
south africa
2015
2015
zimbabwe
1990
2015
1990
2015
GLOBAL NEW HIV INFECTIONS
3 500 000
1990
1995
Current and projected
Investment framework benefit
28 | UNAIDS WORLD AIDS DAY REPORT
2000
2005
2010
2015
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Return on investment
A more strategic approach to spending would achieve extraordinary
results, averting at least 12.2 million new HIV infections, including 1.9
million among children, and 7.4 million AIDS-related deaths between 2011
and 2020 compared with a continuation of current approaches.35 Under
the Investment Framework, the additional investment of US$ 1060 per lifeyear gained would be largely offset by savings in treatment costs alone. To
achieve universal access to HIV treatment, prevention, care and support by
2015, and to maintain it, HIV programme funding needs to be scaled up
from US$ 16.6 billion in 2011 to US$ 24 billion in 2015, before declining to
US$ 19.8 billion in 2020.
Value for money is best obtained when national AIDS responses make
timely investments that are in the right places; utilize the right strategies;
increase efficiency, reduce costs and promote innovation. Each of these
tactics are critical, but when combined, they can lay the foundations for a
sustainable AIDS response.
Supporting countries in the ongoing task of optimizing their responses
through a clearer focus on investment has been embraced by major
providers of international development assistance in AIDS. The investment
approach is in the forefront of the new strategy being developed by the
Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as the HIV
prevention strategy recently issued by the US President’s Emergency Fund
for AIDS Relief. An agenda is emerging which clearly aligns donor interests
in value for money with implementing country interests in optimal results.
Invest adequately, in the right places, with the right strategies
A full and early investment in the AIDS response can reap long-lasting
dividends. Brazil has for years invested adequately and been at the
forefront of ensuring access to HIV prevention and treatment services
for the most vulnerable and marginalized. In 2008, the country invested
more than US$ 600 million, close to the estimate of what is needed for a
full-scale response. The Russian Federation makes an allocation of similar
magnitude, but the value for money realized is not as high as that of Brazil,
as its investment strategy is not optimized.
In the Russian Federation, annual HIV-related investments in 2008 were
close to US$ 800 million, roughly equal to the total amount required in
2015. Yet new HIV infections are increasing, as little of the invested total
goes towards harm-reduction programmes for people who inject drugs,
men who have sex with men or sex workers. Of the US$ 181 million spent
on HIV-prevention programmes in 2008, only US$ 8 million was invested
for these populations. A shift in strategy to embrace harm reduction and
reprioritize existing resources could substantially cut new HIV infections.
Ukraine is beginning to adopt effective programme approaches, but the
scale of investments remains inadequate, incommensurate with the scale
of the epidemic. Ukraine invested nearly one third of its prevention budget
in 2008 towards key affected populations, yet the need is double that
available for people who inject drugs, men who have sex with men and
sex workers. UNAIDS modelling suggests that a doubling of annual AIDSrelated investments in Ukraine and increased coverage of HIV prevention
UNAIDS WORLD AIDS DAY REPORT | 29
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and treatment programmes for people who inject drugs, sex workers and
men who have sex with men could slash 65% off the annual number of new
HIV infections by 2015.
A similar comparison can be made between Cambodia and Viet Nam.
Cambodia is another example of a country where HIV investments matched
the scale of the epidemic and were aligned to epidemiological trends,
resulting in a dramatic reduction in HIV incidence. If this trend continues,
Cambodia may be able to gradually reduce its HIV investments without
compromising the gains made over the last decade. In Viet Nam, however,
investments are not similarly aligned. The epidemic is primarily driven by
injecting drug use and sex between men but coverage and investment
in effective harm reduction programmes for these populations remain
insufficient. An alignment of investments based on the principles of the
investment framework could halve new HIV infections in the country by 2015.
In the case of South Africa, the country with the largest number of new
HIV infections, HIV-related investments have grown significantly in the
past two years and the impact is beginning to show. The rate of new HIV
infections decreased by 22% between 2001 and 2009 and AIDS-related
mortality has decreased by 21% between 2001 and 2010. A stagnation in
levels of investments would lead to a stabilization of the new HIV infections
at about 500 000 per year. However, if South Africa continues to increase
its AIDS investments with domestic and international support, the annual
number of new HIV infections could be reduced to less than 250 000.
Nigeria has the second largest number of new HIV infections in the world
and has insufficient HIV-related investments, severely curtailing its capacity
to address the magnitude of the epidemic. Total HIV investment in 2008
was about US$ 400 million, against a projected annual need of three
times more than that figure by 2015. There is massive potential to reduce
new HIV infections if these investments were to be made in line with
epidemiological trends and appropriate programmatic approaches.
Over the past few years, many countries have begun to taken steps to
examine the epidemiological dynamics and direct resources towards
populations most in need. A recent analysis in Morocco found that only
27% of prevention resources were invested in services for the populations
that accounted for more than two thirds of new HIV infections. The 2012–
2016 National Strategic Plan for Morocco proposes allocating 63% of AIDS
resources towards prevention among key affected populations, including
13% for people who inject drugs, 13% for men having sex with men, and
23% for sex workers and their clients. Such an approach is consistent
with the investment framework and, as country after country has shown,
adequate investment while epidemic levels remain low saves decades of
escalating costs in the future.
Invest in reducing costs
Significant gains can also be made by reducing tariffs and other trade
barriers that increase the unit cost of delivery of HIV treatment and
prevention services. Rigidities and inefficiencies need to be eliminated.
At the urging of UNAIDS, South Africa recently opened its procurement
processes for life-saving antiretroviral drugs and by benchmarking its price
expectations to the lowest available prices internationally, it reduced its
costs for AIDS drugs by an average 50%. In turn, the country channelled
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the savings into making HIV treatment accessible to more people. Many
countries have integrated programmes to stop new HIV infections among
children in existing maternal, newborn and child health services, reducing
costs and maximising efficiencies.
Invest in innovation
Current programme approaches have reached their limits. To increase
efficiencies as well as reduce costs, innovation in programme delivery
methods as well as investing in new HIV prevention and treatment tools is
required.
To provide additional options for
South Africa Post-rape care
HIV treatment and prevention
programmes, the quest for effective
The Refentse Model for Post-Rape Care in South Africa is a
vaccines, easy-to-use drugs, with
multisectoral approach to post-rape care. Relatively inexpensive
fewer side effects and less chance of
changes significantly improved service quality and health outcomes,
resistance developing, microbicides,
with one-stop lab tests, violence counselling and testing services
pre-exposure prophylaxis drugs
around the clock, and nursed-dispensed post-exposure prophylaxis
and better diagnostic tools must
(PEP). Integrating services reduced delays in accessing PEP and
continue. At the same time, it is
collecting medical evidence for legal purposes, and this resulted
necessary to reassess programme
in improvements in care, the quality of clinical history and exams,
delivery models that have outlived
provision of pregnancy testing and emergency contraception; STI
their utility. Almost 60% of all
treatment; HIV counseling and testing; trauma counseling, and
people living with HIV do not know
referrals. This intervention was relatively inexpensive: when one-off
their status, thereby impeding
development costs were excluded, the incremental cost per case was
their ability to look after their own
US$58.36
health and that of their loved ones.
To change this, HIV testing must
become simple and as ubiquitous
as home-based pregnancy test kits. This will drive down the high costs
of maintaining dedicated HIV testing and counselling centres as well as
empowering individuals to access HIV treatment and care services in a
timely and confidential manner.
Innovative service models which deliver on multiple objectives can also
drive improved investment. For example responses to gender based
violence need to integrate HIV components.
Investment Framework for HIV
To ensure that this investment generates maximum results, the HIV
response must focus on the most effective strategies, the critical enablers
that are crucial to the success of HIV programmes, and synergies with other
development sectors.
Just six basic programme activities are essential to an adequate HIV
response and need to be delivered at scale according to the size of the
relevant population. These activities work together for maximum impact
and therefore have to be delivered as a package, where each element
reinforces the other. Underlying the success of these basic activities are
the enablers which make programme access possible and success more
likely and respond to local context. Together with the directly delivered
basic activities and enablers, AIDS-sensitive efforts within wider social and
development sectors can be strategically placed within these broader
efforts to maximize their impact on AIDS outcomes.
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Investment framework allocation in 2015
25.8%
Regional % of global
basic programme
activities
15.7%
Sub-Saharan Africa
55%
Middle East and North Africa
5%
Caribbean and Latin America
11%
West and Central Europe
3%
Eastern Europe and
Central Asia
5%
58.5%
synergies
critical
enablers
Basic programme activities
total resource needs in 2015 (us$ 22-24 billion)
BASIC PROGRAMME ACTIVITIES BY REGION
Key populations at higher risk
Elimination of new HIV infections among children
Behaviour change programmes
Condom promotion
Treatment, care, and support
Voluntary medical male circumcision
The pattern of necessary expenditure on basic programme activities is
driven by the size of the population in need in relation to each activity in
each country. The spending pattern on basic programme activities therefore
varies markedly region to region.
32 | UNAIDS WORLD AIDS DAY REPORT
South and South-East Asia
14%
East Asia and Oceania
7%
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Basic programme activities
The Investment Framework calls for the rational allocation of resources to
six basic programme activities that are required to deliver substantial and
sustainable progress in the HIV response:
1. Focused interventions for key populations at higher risk (particularly sex
workers and their clients, men who have sex with men, and people who
inject drugs);
2. Elimination of new HIV infections among children;
3. Behaviour change programmes;
4. Condom promotion and distribution;
5. Treatment, care and support for people living with HIV;
6. Voluntary medical male circumcision in countries with high HIV
prevalence and low rates of circumcision.
Key populations, by definition, predominate in concentrated epidemics,
but they also contribute to generalized epidemics, and account for a
substantial portion of the epidemic in some countries. Behaviour change
interventions are more complex and context-dependent, so they are
less clearly defined than other basic programme activities, but they have
a major impact on the trajectory of both concentrated and low-scale
epidemics. Access to antiretroviral therapy is a key activity because it
enables people living with HIV to be healthier and live longer, reduces the
incidence of AIDS-related tuberculosis and has broader population benefits
by reducing onward transmission of HIV. Basic programme activities need
to be sufficiently flexible to accommodate evolving technologies and
approaches.
Critical enablers and synergies with development sectors
Critical enablers propel the success of basic activities and respond to the
local risk context. They empower and enable communities, reduce social
stigma, increase health literacy, and address the negative impact of punitive
laws and policies on the ability of people to use HIV services. Advancing
the human rights of those affected by or vulnerable to HIV is a key strategy
which helps assure both access to and impact of AIDS services and
programmes. The Investment Framework provides for substantial up-front
investment in critical enablers, with essential resources amounting to
US$ 5.9 billion in 2011 and US$ 3.4 billion projected for 2015.35
Critical enablers can be divided into two categories: social enablers
that create environments conducive to rational HIV responses; and
programme enablers that create demand for programmes and improve
their performance. Critical enablers vary greatly according to context, and
the evidence base supporting them is less consistent – results are so often
locally determined – but they are crucial to overcoming the barriers to
effective programmes.
Examples of social enablers are outreach for HIV testing, stigma reduction,
human rights, addressing the fear of violence addressing gender
inequality in access to information and services, advocacy and community
mobilization. Programme enablers include strategic planning, programme
management and capacity-building for community-based organizations.
These organizations can foster innovation and community approaches in
the long term can bring down costs and ensure sustainability.
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Proposed Investment Framework
critical
enablers
Social enablers
• Political commitment and
advocacy
• Laws, legal policies and
practices
• Community mobilization
• Stigma reduction
• Mass media
• Local responses to
change risk environment
basic programme activities
Key populations at
higher risk
(particularly sex workers
and their clients, men who
have sex with men, and
people who inject drugs)
Behaviour change
programmes
Eliminate new
HIV infections
among children
Condom promotion
and distribution
Programme enablers
• Community centered
design and delivery
• Programme
communication
• Management and
incentives
• Procurement and
distribution
• Research and innovation
Voluntary medical
male circumcision
Treatment,
care and
support for
people living
with HIV
(in countries with high
HIV prevalence
and low rates of
circumcision)
synergies with development sectors
Social protection, Education, Legal reform, Gender equality, Poverty reduction, Gender-based violence, Health
systems (incl. STI treatment, Blood safety), Community systems, and Employer practices.
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OBJECTIVES
Stopping new infections
National AIDS programmes should be aligned to
country development objectives and thereby support
the strengthening of social, legal, and health systems
to enable sound and effective responses. AIDS
programmes are not implemented in isolation and
should not be planned in isolation. Increasingly, chronic
care of patients with HIV has much the same challenges
as have other diseases. Key development areas in which
synergies with AIDS-specific efforts exist include those
efforts addressing HIV as one of many health issues,
gender equality, education and justice sectors, social
protection and welfare, and community systems.
AIDS funding in these areas can be used as a catalyst
to achieve synergies within the broader health and
development programme and to promote intelligent
investment across several sectors.
Keeping people alive
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Faster.
Smarter.
> Better.
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>Better.
A shift in gears will put the end of AIDS in sight
Uniting behind shared responsibility for common goals
United Nations Member States demonstrated solidarity and a renewed
commitment in June 2011 when they agreed on the Political Declaration
on HIV/AIDS: Intensifying Our Efforts to Eliminate HIV/AIDS.
The 2011 Political Declaration calls for greater efforts to end the epidemic
and it recommits Member States to the goal of universal access to HIV
prevention, treatment, care and support. The Declaration contains
ambitious targets for 2015 and reflects unified support for the vision of
zero new HIV infections, zero discrimination and zero AIDS-related deaths.
The 2011 Political Declaration recognized resource mobilization as a shared
responsibility. The international community provides a substantial amount
of investment in AIDS responses, with bilateral donors (Member States that
provide development assistance directly to recipient countries) providing
31% of investments, multilateral institutions 12%, and the philanthropic
sector 5%. However, the majority of AIDS expenditures in low- and middleincome countries (52%) were provided by domestic sources. Most low- and
middle-income countries are expected to see strong economic growth
in the immediate future, suggesting an increased capacity to devote
additional resources to health, including HIV programmes.
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3.5 million people
New HIV infections, global political responses and investments
Political commitment has helped drive increased HIV investment and turn the
curve of new infections downwards. If all low- and middle-income countries
were to allocate resources in proportion to their HIV burden, domestic publicsector allocations would double by 2017 and continue to rise thereafter.
Economic growth alone should add 22% to AIDS investment by 2015, while
moving closer to health expenditure of 15% of government revenue (as per
the Abuja Declaration for Africa) could add a further 15%. Finally, allocating
these health budgets to HIV according to disease burden could add an
additional 24%. All of these measures taken together could add as much as
62% to investments by 2015, with increases continuing thereafter.
Millennium Declaration
US$ 16 billion
G8 Okinawa Initiative
2006 Political
Declaration
Abuja Declaration
2001 Declaration
of Commitment
2011 Political
Declaration
Doha Declaration
G8 Gleneagles Pledge
Gates Foundation
PEPFAR
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
The Global Fund
New HIV infections
Resources available for HIV in low- and middle-income countries
12
Domestic Investment in low- and
middle-Income countries, US$ billion
Projected HIV domestic resources
available under various scenarios
While countries in all regions can
expand their allocations for HIV,
those hardest hit are also often those
with least resources. Hence, there is
the need for international donors to
continue supporting programmes,
especially in the poorest and
worst affected countries. After
an increased initial investment of
US$ 2.6 billion annually, the donor
funding required is estimated to
decline after 2015.
10.3
10
8.8
7.8
8
6.4
6
4
2
0
2010
2015 with
economic growth
2015 with
economic growth
and 15% health
budget
2015 with
economic growth,
15% health budget
and allocation by
disease burden
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A better future: the global plan to eliminate new HIV infections
among children
The world has embarked on a course to virtually eliminate new HIV
infections among children.
The Kesho Bora (“better future”) study from Africa demonstrated that when
mothers took a triple antiretroviral drug regimen during pregnancy and
breastfeeding, the risk of HIV transmission was almost halved compared
with women who took two drugs only.37 This approach is already being
implemented in countries, reflecting swift translation of research into
action.
With improved treatment regimens and strengthened commitment to a
comprehensive response, it now seems feasible by 2015 to eliminate new
HIV infections among children and to keep their mothers alive. New HIV
infections among children have already been virtually stopped in highincome countries, with the number of new infections among children
falling by 93% between 1992 and 2005 in the United States of America.38
Comparable results can be achieved in low- and middle-income countries.
Progress to date is already considerable. More than 350 000 new HIV
infections among children have been averted by providing antiretroviral
prophylaxis to pregnant women living with HIV. New child infections were
rising until 2002 when they reached their peak of 560 000 [500 000–
630 000]. By 2010 they had fallen to an estimated 390 000 [340 000–
450 000]. The majority of child infections averted (86%) were in subSaharan Africa. The pace of progress has been increasing. In the past two
years alone, rapid increase of coverage of HIV treatment and prevention
services for pregnant women resulted in a doubling of cumulative HIV
infections averted. In 2010, 48% of pregnant women living with HIV
received effective regimens to prevent new HIV infections among children.
Estimated percent of pregnant women living with HIV who receive
effective antiretroviral regimens, in 22 priority countries
Too many of the 22 countries in the Global Plan still have significant gaps
in their coverage of basic programmes to give pregnant women access to
antiretrovirals to prevent new HIV infections among children.
40%–79%
0%–39%
Cameroon
Côte d’Ivoire
Ghana
Burundi
Kenya
Chad
Mozambique
Botswana
Dem. Rep. of Congo
Uganda
Lesotho
India
United Republic of Tanzania
Namibia
Malawi
Zambia
South Africa
Nigeria
Zimbabwe
Swaziland
Source: UNAIDS, UNICEF and WHO, 2011.
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>80%
Angola
Note: no estimate is available for Ethiopia.
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New HIV infections among children: Scenarios for
21 priority countries
New infections among children would be cut dramatically by expanding
antiretroviral coverage, reducing adult incidence and meeting family
planning needs.
400 000
0
2009
2011
2013
2015
2010 coverage maintained
90% coverage of highly effective antiretrovirals
90% ARV coverage; 50% reduction in incidence; no unmet need for family planning
Note: These 21 countries, plus India, comprise the 22 priority countries in the Global Plan Towards the
Elimination of New HIV infections Among Children and Keeping Their Mothers Alive.
Botswana reports that the percentage of infants who are born HIV-positive
to mothers living with HIV has declined from 21% in 2003 to 4% in 2010.39
Countries with a high burden of new HIV infections among children –
Lesotho, Namibia, South Africa and Swaziland – have likewise achieved
universal access to services to prevent new HIV infections among children.
AIDS-related deaths among children younger than 15 also have declined.
There were 20% fewer AIDS-related deaths among children in 2010 than
in 2005. This is due both to fewer new HIV infections among children and
to an increase in HIV treatment for children (albeit at a slower rate than the
increase in treatment for adults).
As outlined in the Global Plan Towards the Elimination of New HIV
Infections Among Children by 2015 and Keeping Their Mothers Alive,
action is required in four areas. First, intensified efforts are needed to
prevent HIV infection in women of reproductive age by stopping sexual
and injecting-drug-related transmission. Primary HIV prevention efforts
should also be integrated in antenatal care, postpartum care, and other
health and HIV service-delivery channels.
Second, the access gap for women’s family-planning services must be
closed. These services enable women to avoid unintended pregnancies
and optimize other health outcomes.
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Third, pregnant women should routinely be offered HIV testing and
counselling, and pregnant women living with HIV and their newborns
should have guaranteed access to antiretroviral drugs to reduce the odds
of HIV transmission during pregnancy, delivery or breastfeeding. Infant
feeding counselling and support should be provided.
Fourth, HIV care, treatment and support should be universally available to
women, children living with HIV, and their families. Success in this area will
demand efforts to close gaps in children’s access to early infant diagnosis
and paediatric care and treatment services, as well as initiating lifelong
antiretroviral therapy for HIV-positive pregnant women.
Currently the distribution of regimens in the 22 priority countries from the
Global Plan includes about 13% single dose NVP, 32% on dual prophylaxis
and the remaining 7% on highly effective ARVs or ART. This has resulted in
a mother to child transmission rate of approximately 27%. If the 22 priority
countries shifted all women in their PMTCT programmes from their current
regimens to the recommended regimens there would be an immediate
20% drop in the number of new HIV infections among children. Using only
recommended regimens in the 22 priority countries would have limited the
number of new HIV infections among children to 280 000 instead of
350 000 in 2010.
Distribution of antiretroviral regimens to prevent new HIV infections
among children: 22 priority countries, 2004–2010
The proportion of women receiving more optimal antiretroviral therapy
has increased rapidly since the initial recommendation of 2006 that
programmes should where possible move beyond single dose nevirapine.
100%
ART for the woman’s
own health
90%
Triple ARV prophylaxis
Dual ARV prophylaxis
80%
Single dose NVP
70%
60%
50%
40%
30%
20%
10%
0%
2004
2005
2006
2007
Source: Aggregated data from national HIV estimates files, UNAIDS 2011.
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2008
2009
2010
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Programmes should view their interactions with pregnant women as an
opportunity to reach families, including offering couples counselling and
testing, and support for mutual disclosure. About half of all people with
HIV who are in a long-term stable relationship have a sero-negative partner,
with such couples accounting for a substantial share of new infections in
Rwanda, Uganda, Zambia, and other countries with mature epidemics.40-42
Globally, the amount needed to eliminate new HIV infections among
children is estimated to be an additional US$ 1.5 billion annually by 2015.
Innovation in ART to deliver better
population outcomes
Biomedical innovation – in particular
through accelerated use of
antiretrovirals – has the potential to
dramatically increase the progress
of the AIDS response.
Supporting pregnant women in South Africa
South Africa now provides an estimated 95% of eligible women
with antiretrovirals to prevent new HIV infections among children,
up from 57% coverage in 2007. This achievement reflects political
commitment, strong civil society engagement, decentralized service
delivery, and empowerment of nurses to administer antiretroviral
prophylaxes.
In 2011, a trial among couples in
which one partner was HIV-positive
confirmed that antiretroviral
therapy significantly contributes to HIV prevention. The nine-country trial
randomized the couples into two groups: one in which the partner living
with HIV received early antiretroviral therapy (when the CD4 count was
between 350 and 550 cells per cubic millilitre); and the other in which
treatment would be initiated at the then standard point of initiation (when
the CD4 count fell to 250 cells). The trial found that treatment reduced
the relative risk of HIV transmission by 96%.16
Antiretroviral therapy, therefore, has the dual benefit of reducing the
risk of HIV-related illness and death for people living with HIV, and
significantly reducing the likelihood of onward HIV transmission. To
strengthen HIV prevention, urgent efforts are needed to scale up
antiretroviral therapy programmes to reach the 7.6 million people who
were eligible for treatment at the end of 2010 (those with CD4 counts less
than 350) but who were not receiving it.
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Using antiretrovirals for people not infected with HIV, to prevent
acquisition
Recent research reveals the efficacy of pre-exposure use of antiretroviral
drugs to prevent HIV infection. In 2010, a multi-country study among
men who have sex with men found that daily antiretroviral tablets
reduced the risk of becoming HIV positive by 44%, with substantially
greater protection afforded to those who rigorously adhered to the daily
preventive regimen.43 In 2011, two additional trials determined that such
daily oral pre-exposure prophylaxis, known as PrEP, reduced the likelihood
of HIV transmission among heterosexual adults by more than 60%.44,45
Community trials of ART to boost prevention
The HPTN 052 trial has shown that treating an HIV-infected
individual with ART reduces the risk of sexual transmission of HIV to
an uninfected partner, and mathematical modeling indicates that
important prevention benefits can be expected from scaled-up
antiretroviral treatment in communities. However, the epidemiological
evidence of such impact at the level of entire countries may not be
clearly apparent from national surveillance data, as it may be difficult
to distinguish the specific impact on incidence of antiretroviral
treatment from that of other prevention activities.
Further research is needed to unequivocally establish and quantify
the effect of antiretroviral treatment on HIV incidence in communities
and countries. Several such studies are now being prepared,
including the ‘Population ART’ study, which is scheduled to start in
2012. The study will test the impact of a combination prevention
strategy that combines community-wide house-to-house voluntary
testing for HIV, the offer of medical circumcision to men who test HIVnegative, and the offer of immediate initiation of antiretroviral therapy
(ART) for all those testing HIV-positive in communities in Zambia and
South Africa. Similar studies are planned in Botswana, South Africa
and the United Republic of Tanzania.
New research indicates preexposure prophylaxis is effective
when applied topically as a vaginal
microbicide. In 2010, South African
researchers reported that 1%
tenofovir gel lowered the risk of
male-to-female sexual transmission
by 39%, rising to 54% in women
who used the vaginal gel for more
than 80% of their sex acts.46
Ongoing trials aim to confirm
the South Africa microbicide trial
results, with the hope of making
an effective microbicide widely
available as early as 2014. Trials are
also under way to investigate the
efficacy of intermittent oral preexposure prophylactic regimens
that allow for less-than-daily use
of tablets. Additional research is
assessing the long-term safety
of antiretroviral prophylaxis, the
possibility that such use could
increase levels of antiretroviral drug
resistance, and the population-level
benefits of PrEP programmes.
While the results of pre-exposure prophylaxis trials have not been as clearcut as the results of ART use to prevent transmission, modelling suggests
that scale-up of these new methods would prevent a substantial share of
incident infections, hastening the overall decline in HIV incidence.47-49
Vaccine research
As efforts are made to introduce new HIV prevention tools, continued
investment in research and development for a preventive vaccine is
essential. In 2009, results from a large community trial in Thailand found
that recipients of a combination vaccine regimen were 31.2% less likely
over 42 months to become infected than trial participants who did not
receive the vaccine.50 Although this degree of efficacy did not warrant
immediate licensing of the vaccine, the trial demonstrated for the first
time that an HIV vaccine is feasible. Research is underway to assess the
effects of additional doses of vaccine to boost immunity and to determine
whether this vaccine regimen is equally effective against HIV subtypes
found in sub-Saharan Africa.
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Delivering a better package
Maximising the impact of AIDS programme efforts and incorporating
innovation to further drive down new infections and save lives requires
programme efforts that function together. The new HIV prevention
breakthroughs confer partial
protection and depend on
An incidence measure is urgently needed
behaviour for their uptake. Ability to
to guide better HIV responses
adhere to a treatment regimen, for
example, is a crucial determinant of
Prevalence gives little insight into the contemporary dynamics of HIV
whether ARVs will work to prevent
transmission or the outcomes of prevention programmes. Indeed,
either transmission or acquisition
prevalence measures the cumulative toll of an epidemic including
of HIV. Equally, male circumcision
the number of people who have been infected in past years and
efforts would be undermined if
the effect that antiretroviral therapy has by keeping people living
they resulted in condom use being
with HIV alive for longer. Instead, incidence reflects changes in HIV
abandoned. Fortunately to date
transmission and the effects of prevention programmes including
this has not been observed in
the effect of antiretroviral treatment programmes. Currently, most
circumcision roll-out programmes.
population-wide incidence data are derived from mathematical
Similarly, stigma can fatally
models.
undermine HIV efforts across
the board. This emphasizes the
continuing need for a combination
of approaches, including
biomedical, behavioural and
structural components, all directed
at the objectives of reducing HIV
risk and reducing morbidity and
mortality.
As the UNAIDS High Level Commission on HIV Prevention argued
in 2010, “Countries, donors, researchers and multilateral institutions
should shift from prevalence data to assessing incidence for policy
decisions and assessing the effectiveness of programmes.” Indeed,
investments to reduce new infections could be better targeted to the
most effective programmes if a quick, easy, valid, and precise method
of estimating incidence in populations was available.
However, despite more than a decade of development of incidence
tests, today there is still no validated incidence assay that can be
used to estimate population-level incidence. In a world where we
need to be able to assess in a timely manner the real-world impacts
that different prevention programmes are having, developing and
validating a reliable incidence essay is essential. Appropriate levels of
funding should be directed to this effort.
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Winning the race against AIDS
The visionary goals adopted at the United Nations General Assembly in
the 2011 Political Declaration on HIV/AIDS heralded a moment of truth
in the global AIDS response. By uniting to achieve the stated targets for
2015, the global community can move towards a world with zero new HIV
infections, zero discrimination and zero AIDS-related deaths.
Adopting a more focused and strategic approach to AIDS is essential for
success. The world will succeed in meeting the targets for 2015 if sufficient
and strategic investments are made in efficient and effective programmes.
Now is the time for action, the time to translate words of commitment into
meaningful and lasting results for people. By mobilizing the political will,
showing international solidarity and commitment, improving the strategic
use of resources, and effectively deploying available tools, it will be
possible to arrive at a world in 2015 that is decidedly healthier, more just
and more inclusive than today.
The knowledge and the tools to defeat AIDS now exist. Decisions made
now will determine whether this is truly the beginning of the end of AIDS.
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Notes
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and challenges. Journal of Acquired Immune
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2. Country report on the follow-up to the
Declaration of Commitment on HIV/AIDS. Jakarta,
National AIDS Commission Indonesia, 2008.
3. HIV/AIDS surveillance in Europe 2009.
Stockholm, European Centre for Disease
Prevention and Control, and WHO Regional Office
for Europe, 2010.
4. Updated analyses based on Hallett TB et al.
Assessing evidence for behaviour change affecting
the course of HIV epidemics: a new mathematical
modelling approach and application to data from
Zimbabwe. Epidemics, June 2009, 1(2):108-17.
5. Bello G et al. Evidence for changes in behaviour
leading to reductions in HIV prevalence in urban
Malawi. Sexually Transmitted Infections 2011,
87:296–300.
6. Jewkes RK et al. Intimate partner violence,
power inequity, and incidence of HIV infection in
young women in South Africa: a cohort study. The
Lancet, 2010, 376:41–48.
7. Bailey RC et al. Male circumcision for HIV
prevention in young men in Kisumu, Kenya: a
randomized controlled trial. The Lancet, 2007,
369:643–656.
8. Gray RH et al. Male circumcision for HIV
prevention in men in Rakai, Uganda: a randomized
trial. The Lancet, 2007, 369:657–666.
9. Auvert B et al. Randomized, controlled
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of HIV infection risk: the ANRS 1265 trial. Public
Library of Science Medicine, 2005, 2:e298.
Marguerite Ndour and Isaac Minani, of Projets
Sida-1-2-3 (funded by CIDA from 1993–2006); and
all staff of the National AIDS Control Program of
Benin for the implementation of the intervention
and the conduct of the field surveys).
14. Shaboltas A et al. HIV incidence, gender and
risk behaviors differences in injection drug users
cohorts, St. Petersburg, Russia. XVIII International
AIDS Conference, Vienna, Austria, 18–23 July 2010
(Abstract TUPE0331; http://www.iasociety.org/
Default.aspx?pageid=11&abstractid=200740055,
accessed 15 October 2011).
15. Curtis M. Delivering HIV care and treatment for
people who use drugs: lessons from research and
practice. New York, Open Society Institute, 2006.
16. Cohen MS et al. Prevention of HIV-1 infection
with early antiretroviral therapy. New England
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17. Dlodlo RA et al. Adult mortality in the cities
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Journal of the International AIDS Society, 2011,
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Jahn A et al. Population-level effect of HIV on
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Reniers G et al. Steep declines in populationlevel AIDS mortality following the introduction of
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HERBST, Abraham J et al. Adult mortality and
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18. Mathers BM et al. Global epidemiology of
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10. Auvert B et al. Effect of the Orange Farm
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on HIV Pathogenesis, Treatment, and Prevention,
Rome, 17–20 July, 2011. Abstract No. WELBC02.
19. Country report on monitoring of the United
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en/dataanalysis/monitoringcountryprogress
/2010progressreportssubmittedbycountries/
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11. Progress in scale-up of male circumcision for
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20. Reference Group to the United Nations on
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idurefgroup.org/results/Iran,+Islamic+Republic_
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12. Based on: Report of a Consensus Workshop:
HIV Estimates and Projections for Cambodia,
2006 – 2012. National Center for HIV/AIDS,
Dermatology and STD, Ministry of Health, Royal
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